Provider and Member Services Standardization for Leading Healthcare Payer Operations

Processes for 3,000 employees mapped in just seven weeks

A Top 3 regional health insurance provider sought to drive new efficiencies while improving customer experience—two objectives which often seem at odds with one another.

The COO of administrative operations for this regional health-insurance giant, which employs 3,000 people across four locations in three states, wanted to take a new approach to the challenge. Previously in her career, she had been a manufacturing engineer. Looking for quick and massive wins, she tasked her internal operations consulting team with productivity improvement. Their lean methodology succeeded—at small scale. This was far from the “massive” benefit which the COO desired.

She then reached out to The Lab, North America’s respected resource for end-to-end (E2E) process mapping, automation-opportunity discovery, and implementation of standardized knowledge-work activities and RPA or robotic process automation.

The limitations of earlier attempts

The COO saw how previous efforts had fallen short: Cutting costs would deliver short-term gains. Headcount would shrink, but administrative errors wouldn’t.

Customers flooded the phones with complaints. As noted above, most managers viewed healthcare payer operations cost-reduction and service-improvement as competing goals. Meanwhile, low-cost competitors were stealing customers.

End-to-end improvement of enterprise health insurance operations required first mapping the processes, a specialty of The Lab. The detailed process maps quickly let health-insurance leaders see bottlenecks, inefficiencies, and rework; they also call out opportunities for robotic process automation “bots” that can “sit at the computer” and take over the kinds of low-value chores that have employees heading for the exits.


Scope of project

The Lab’s marching orders were broad and deep. The project encompassed a wide swath of enterprise operations, including:

  • Provider services and operations
  • Membership operations
  • Membership claims
  • Member services

Each value stream warranted its own map. Surprisingly, the E2E mapping took only seven weeks, with minimal input required of the insurer’s sponsors, staff, and subject matter experts or SMEs. The Lab routinely performs end-to-end mapping of both business processes and customer journeys, remotely from our U.S. offices in Houston, with nothing outsourced or offshored, in just weeks.

Once the mapping was complete, the benefit opportunities quickly surfaced. The Lab identified more than 200 discrete improvements; some could harness the power of RPA, while others would require no technology whatsoever. Examples include:

  • Standardization of data submission formats. Prior to The Lab’s intervention, providers submitted data in nonstandard formats. It wasn’t their fault; there were no guidelines for submission of data. As a result, the insurance company’s operations employees were forced to reformat most of the incoming data: an incredible time-waster, not to mention morale-crusher. In just three weeks, The Lab implemented new, standardized data-submission guidelines. Monitoring compliance with these new standards reduced reformatting by 80 percent.
  • Eliminated recurring errors—and resulting rework. The Lab’s analysis revealed that only a small minority of recurrent errors generated the most corrections. Similarly, inaccurate, outdated membership files caused errors with the highest customer impact. The implementation of just seven new standardized operations process improvements reduced membership errors by more than half.
  • Customer service calls, pre-empted upstream.The company’s website provided numerous self-service options. But as it turned out, Member Services failed to promote them. Analysis by The Lab revealed that avoidable calls for information accounted for nearly one-half of total call volume. Newly implemented advertising to promote the already-available self-service options eliminated 60 percent of informational queries within just three months.

Automation opportunities abound

For every sit-at-the computer chore which staffers detest performing, there’s a bot, configurable by The Lab, to handle it. Mundane, tedious, and error-prone activities, in which staffers function as “the human glue” between disparate systems that don’t talk to each other, are ideal opportunities for “parking an RPA bot.”

Bots from The Lab can typically be configured in just weeks. We use the best teams and developers, working remotely from our U.S. offices in Houston, with nothing ever outsourced or offshored.

RPA bots from The Lab not only speed up health insurance operations. They virtually eliminate errors. More importantly, they improve employee morale and talent retention, since key staffers are freed to focus on more valuable and fulfilling activities.

Meaningful, self-funding results

The Lab’s initial scoping, analysis, and mapping took just seven weeks. This leading health insurer then retained The Lab for implementation of our findings, which spanned six months.

The engagement was entirely self-funding, with a guaranteed business case. The overall results, in addition to the details noted above, were impressive:

  • Knowledge worker capacity increased by 25 percent.
  • Operating costs were reduced by 25 percent.
  • Savings were $26M.

The project broke even in just five months. The 12-month ROI was tenfold.

The best way to appreciate this speed and game-changing power is to see it for yourself. We invite you to schedule your free, no-obligation 30-minute screen-sharing demo with The Lab. You’ll see real RPA banking bots in action, and get all your questions answered by our friendly experts.

Simply contact The Lab today at (201) 526-1200 or email us at to book your free screen-share bot demo.


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